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Patient Intake Form

Personal Information(Required)
Date of Birth(Required)
What condition(s) are you seeking treatment for at our clinic?(Required)
Please mark all that apply
Which of the following treatments are you interested in?(Required)

Health Information

Have you ever received any form of ketamine therapy (infusions, lozenges, Spravato, etc)?*(Required)
If none, type "n/a" or "none"
If none, type "n/a" or "none"
If none, type "n/a" or "none"
If none, type "n/a" or "none"
Have you ever experienced any of the following heath problems? *(Required)

18205 N 51st Ave STE 126,
Glendale, AZ 85308
(602) 922-8527
Mon - Thu: 7am–4:30pm
Fri: 8am–12pm
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